01-11-2006 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling LG230 Application to Conduct Off -Site Gambling No Fee 5/04 Licensed Organization Information Jglease rig{ I information) / q Organization name 46 /i�-/V DJfVS , � /UC. License number 6-0(4 // License expiration date 0 3 / 3 / / 66 Daytime phone number £S / —776 -013,1 f3PPugiO Frig New Llee -Alsg ro 3- 3/ -o8» Name of chief executive officer ifTfv/270 Ai 0 -1059-7JSo A (Do not list the gambling manager) Gambling Activity 1. Name of establishment or function where/ gamblli inn gacctiviittylwillbecondurcted� 61,01/ l ' i^,(/O )l,,/1•7�/ 2. Street address and city 350 eL/ iet,) r 2 / 2irnlC &/cck/iW ////V t j (Do not use a post office box. If no street address, write in road designations. Example: 3 miles east of Hwy. 63 on County Road 42) 3. Does your organization own the gambling premises? Yes If yes, a lease is not required. 1/No If no, a lease agreement must be attached. You may use lease form LG224, available from the Board. NOTE: A lease is not required for raffles. 4. Check the gambling activity your organization will be conducting. V pull -tabs tipboards raffles paddlewheels _bingo 5. Date of single day event (4 separate days allowed per calendar year) 6. Dates of up to 12 consecutive days in connection with a county fair, the state fair, a church festival, or a civic celebration. Begin date g'5 ioi-O6 End date D —b -0 6 (1 event allowed per calendar year) Acknowledgment and Oath I have read this application, and all information is true, accurate, and complete. Chief executive officer signa ure ri ��G =�n�� . "" , Date O // C U 6 *Ar- ne person signing this application m the CEO of your organization and have his or her name on file with the Gambling Control Board. If the CEO has changed during the term of your license and has not filed a LG200B Organization Officers Affidavit with the Gambling Control Board, he or she must do so at this time. Application and attachments: At least 30 days prior to the activity date, submit: 1) this application, 2) the resolution of approval from the local unit of government (city or county), and 3) a copy of the lease agreement (no lease required if your organization owns the premises or for raffle activity) There is no application fee. Mail to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113 Questions? Contact your licensing specialist at 651- 639 -4000. If you use a 1 I Y, you can call the Board by using the Minnesota Relay Service and ask to place a call to 651-639 -4000. This publication will be made available in alternative format (i.e. large print. Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine yourqualificationstobe involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however. if you refuse to supply this information, the Board may not be able to determine your qualifications and. as a consequence, may refuse to issue you a permit. If you supplythe information requested. the Board will be ableto process your application. This form may requi re the disclosure of your Social Security number. If so, your Social Security number will he used to determine your compliance with the tax laws of Minnesota. Authorizationforrequiring your Social Security numherisfound at42U.S.C. 405 (c)0). Your name and address will be public information when received by the Board. All the other information that you providewill be private data about you untilthe Board issuesyour permit. When the Board issues your permit, all of the information that you have providedtothe Board in the process ofapplyingforyourpermitwill become public except for your Social Security number, which remains private. If the Board does not issue you a permit. all the information you have provided in the process of applying for a permit remains private. with the exception ofyourname 5 and address which will remain public. Private data about you areavailableonlyto the following: Board members, staff of the Board whose work assignmentrequiresthatthey have accesstothe information; the Minnesota Department of Public Safety; the Minnesota Attorney General: the Minnesota Commissioners of Administration, Finance. and Revenue:the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given: and anyone with your consent.